Persistent Atrial Fibrillation (persistent + atrial_fibrillation)

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Selected Abstracts


A Short-Term, Randomized, Double-Blind, Parallel-Group Study to Evaluate the Efficacy and Safety of Dronedarone versus Amiodarone in Patients with Persistent Atrial Fibrillation: The DIONYSOS Study

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 6 2010
JEAN-YVES LE HEUZEY M.D.
Dronedarone versus Amiodarone in Patients with AF.,,Introduction: We compared the efficacy and safety of amiodarone and dronedarone in patients with persistent atrial fibrillation (AF). Methods: Five hundred and four amiodarone-na´ve patients were randomized to receive dronedarone 400 mg bid (n = 249) or amiodarone 600 mg qd for 28 days then 200 mg qd (n = 255) for at least 6 months. Primary composite endpoint was recurrence of AF (including unsuccessful electrical cardioversion, no spontaneous conversion and no electrical cardioversion) or premature study discontinuation. Main safety endpoint (MSE) was occurrence of thyroid-, hepatic-, pulmonary-, neurologic-, skin-, eye-, or gastrointestinal-specific events, or premature study drug discontinuation following an adverse event. Results: Median treatment duration was 7 months. The primary composite endpoint was 75.1 and 58.8% with dronedarone and amiodarone, respectively, at 12 months (hazard ratio [HR] 1.59; 95% confidence interval [CI] 1.28,1.98; P < 0.0001), mainly driven by AF recurrence with dronedarone compared with amiodarone (63.5 vs 42.0%). AF recurrence after successful cardioversion was 36.5 and 24.3% with dronedarone and amiodarone, respectively. Premature drug discontinuation tended to be less frequent with dronedarone (10.4 vs 13.3%). MSE was 39.3 and 44.5% with dronedarone and amiodarone, respectively, at 12 months (HR = 0.80; 95% CI 0.60,1.07; P = 0.129), and mainly driven by fewer thyroid, neurologic, skin, and ocular events in the dronedarone group. Conclusion: In this short-term study, dronedarone was less effective than amiodarone in decreasing AF recurrence, but had a better safety profile, specifically with regard to thyroid and neurologic events and a lack of interaction with oral anticoagulants. (J Cardiovasc Electrophysiol, Vol. 21, pp. 597-605, June 2010) [source]


Automatic 3D Mapping of Complex Fractionated Atrial Electrograms (CFAE) in Patients with Paroxysmal and Persistent Atrial Fibrillation

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 9 2008
JINJIN WU M.D.
Background: Complex fractionated atrial electrograms (CFAE) are a possible target for atrial fibrillation (AF) ablation and can be visualized in three-dimensional (3D) mapping systems with specialized software. Objective: To use the new CFAE software of CartoXP« (Biosense Webster, Diamond Bar, CA, USA) for analysis of spatial distribution of CFAE in paroxysmal and persistent AF. Methods: We included 16 consecutive patients (6 females; mean 59.3 years) with AF (6 paroxysmal and 10 persistent) undergoing AF ablation. Carto maps of left atrium (LA) were reconstructed. Using the new CFAE software, the degree of local electrogram fractionation was displayed color-coded on the map surface. LA was divided into four regions: anterior wall, inferior wall, septum, and pulmonary veins (PV). The relationship among regions with CFAE visualized and CFAE ablation regions (persistent AF only) was analyzed retrospectively. Results: In paroxysmal and persistent AF, CFAE were observed in all four LA regions. In paroxysmal AF, the density of CFAE around the PV was significantly higher than in other regions (P < 0.05) and higher than in persistent AF (P < 0.05). In persistent AF, CFAE were evenly distributed all over the LA. Of 40 effective ablation sites with significant AF cycle length prolongation, 33 (82.5%) were judged retrospectively by CFAE map as CFAE sites. Conclusion: CFAE software can visualize the spatial distribution of CFAE in AF. CFAE in persistent AF were observed in more regions of LA compared to paroxysmal AF in which CFAE concentrated on the PV. Automatically detected CFAE match well with ablation sites targeted by operators. [source]


Catheter Ablation of Long-Lasting Persistent Atrial Fibrillation: Critical Structures for Termination

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 11 2005
MICHEL HA¤SSAGUERRE M.D.
Background: The relative contributions of different atrial regions to the maintenance of persistent atrial fibrillation (AF) are not known. Methods: Sixty patients (53 ▒ 9 years) undergoing catheter ablation of persistent AF (17 ▒ 27 months) were studied. Ablation was performed in a randomized sequence at different left atrial (LA) regions and comprised isolation of the pulmonary veins (PV), isolation of other thoracic veins, and atrial tissue ablation targeting all regions with rapid or heterogeneous activation or guided by activation mapping. Finally, linear ablation at the roof and mitral isthmus was performed if sinus rhythm was not restored after addressing the above-mentioned areas. The impact of ablation was evaluated by the effect on the fibrillatory cycle length in the coronary sinus and appendages at each step. Activation mapping and entrainment maneuvers were used to define the mechanisms and locations of intermediate focal or macroreentrant atrial tachycardias. Results: AF terminated in 52 patients (87%), directly to sinus rhythm in 7 or via the ablation of 1,6 intermediate atrial tachycardias (total 87) in 45 patients. This conversion was preceded by prolongation of fibrillatory cycle length by 39 ▒ 9 msec, with the greatest magnitude occurring during ablation at the anterior LA, coronary sinus and PV-LA junction. Thirty-eight atrial tachycardias were focal (originating dominantly from these same sites), while 49 were macroreentrant (involving the mitral or cavotricuspid isthmus or LA roof). Patients without AF termination displayed shorter fibrillatory cycles at baseline: 130 ▒ 14 vs 156 ▒ 23 msec; P = 0.002. Conclusion: Termination of persistent AF can be achieved in 87% of patients by catheter ablation. Ablation of the structures annexed to the left atrium,the left atrial appendage, coronary sinus, and PVs,have the greatest impact on the prolongation of AF cycle length, the conversion of AF to atrial tachycardia, and the termination of focal atrial tachycardias. [source]


Reversal of Electrical Remodeling After Cardioversion of Persistent Atrial Fibrillation

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 5 2004
MERRITT H. RAITT M.D.
Introduction: In animals, atrial fibrillation results in reversible atrial electrical remodeling manifested as shortening of the atrial effective refractory period, slowing of intra-atrial conduction, and prolongation of sinus node recovery time. There is limited information on changes in these parameters after cardioversion in patients with persistent atrial fibrillation. Methods and Results: Thirty-eight patients who had been in atrial fibrillation for 1 to 12 months underwent electrophysiologic testing 10 minutes and 1 hour after cardioversion. At 1 week, 19 patients still in sinus rhythm returned for repeat testing. Reverse remodeling of the effective refractory period was not uniform across the three atrial sites tested. At the lateral right atrium, there was a highly significant increase in the effective refractory period between 10 minutes and 1 hour after cardioversion (drive cycle length 400 ms: 204 ▒ 17 ms vs 211 ▒ 20 ms, drive cycle length 550 ms: 213 ▒ 18 ms vs 219 ▒ 23 ms, P < 0.001). The effective refractory period at the coronary sinus and distal coronary sinus did not change in the first hour but had increased by 1 week. The corrected sinus node recovery time did not change in the first hour but was shorter at 1 week (606 ▒ 311 ms vs 408 ▒ 160 ms, P = 0.009). P wave duration also was shorter at 1 week (135 ▒ 18 ms vs 129 ▒ 13 ms, P = 0.04) consistent with increasing atrial conduction velocity. Conclusion: The atrial effective refractory period increases, sinus node function improves, and atrial conduction velocity goes up in the first week after cardioversion of long-standing atrial fibrillation in humans. Reverse electrical remodeling of the effective refractory period occurs at different rates in different regions of the atrium. (J Cardiovasc Electrophysiol, Vol. 15, pp. 507-512, May 2004) [source]


Fractionation of Electrograms and Linking of Activation During Pharmacologic Cardioversion of Persistent Atrial Fibrillation in the Goat

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 5 2004
ZHAOLIANG SHAN M.D.
Introduction: During atrial fibrillation (AF), there is fractionation of extracellular potentials due to head-to-tail interaction and slow conduction of fibrillation waves. We hypothesized that slowing of the rate of AF by infusion of a Class I drug would increase the degree of organization of AF. Methods and Results: Seven goats were instrumented with 83 epicardial electrodes on the left atrium, left atrial appendage, Bachmann's bundle, right atrium, and right atrial appendage. AF was induced and maintained by an automatic atrial fibrillator. After AF had persisted for 4 weeks, the Class IC drug cibenzoline was infused at a rate of 0.1 mg/kg/min. AF cycle length (AFCL), the percentage of fractionated potentials, conduction velocity (CV), and direction of propagation of the fibrillation waves were measured during baseline, after AFCL was increased by 20, 40, 60, and 80 ms, and shortly before cardioversion. Infusion of cibenzoline increased the mean of the median AFCLs from 96 ▒ 6 ms to 207 ▒ 43 ms (P < 0.0001). The temporal variation in AFCL in different parts of the atria was 8% to 20% during control and, with the exception of Bachmann's bundle, was not significantly reduced during cibenzoline infusion. CV decreased from 76 ▒ 14 ms to 52 ▒ 9 cm/s (P < 0.01). Cibenzoline increased the percentage of single potentials from 81%▒ 4% to 91%▒ 4% (P < 0.01) and decreased the incidence of double potentials from 14%▒ 4% to 7 ▒ 5% (P < 0.01) and multiple potentials from 5%▒% to 1%▒ 2% (P < 0.001). Whereas during control, linking (consecutive waves propagating in the same direction) during seven or more beats occurred in 9%▒ 15% of the cycles, after cibenzoline the degree of linking had increased to 40%▒ 33% (P < 0.05). During the last two beats before cardioversion, there was a sudden prolongation in AFCL from 209 ▒ 37 ms to 284 ▒ 92 ms (P < 0.01) and a strong reduction in fractionated potentials (from 22%▒ 12% to 6%▒ 5%, P < 0.05). Conclusion: The Class IC drug cibenzoline causes a decrease in fractionation of fibrillation electrograms and an increase in the degree of linking during AF. This supports the observation that Class I drugs widen the excitable gap during AF. (J Cardiovasc Electrophysiol, Vol. 15, pp. 572-580, May 2004) [source]


Effect of Electrical and Structural Remodeling on Spatiotemporal Organization in Acute and Persistent Atrial Fibrillation

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 10 2002
JOSEPH G. AKAR M.D.
Spatiotemporal Organization in Atrial Fibrillation.Introduction: Atrial fibrillation (AF) may originate from discrete sites of periodic activity. We studied the effect of structural and electrical remodeling on spatiotemporal organization in acute and persistent AF. Methods and Results: Atrial effective refractory periods (AERPs) were recorded from five different sites at baseline and after pacing in acute AF (n = 8 dogs) and persistent AF (n = 8). Four persistent AF dogs subsequently were cardioverted to sinus rhythm to allow AERP recovery. Periodicity was quantified by calculating power spectra on left atrial electrograms obtained from a 64-electrode basket catheter. Left atrial size was measured by intracardiac echocardiography and structural changes were assessed by electron microscopy. Mean AERPs decreased after pacing in acute (128 ▒ 16 msec to 108 ▒ 29 msec, P < 0.001) and persistent AF (135 ▒ 16 msec to 104 ▒ 24 msec, P < 0.0001). AERP recovery was established after 7 days of sinus rhythm. Structural changes were mild in acute AF, severe in persistent AF, and remained severe after AERP recovery. A single dominant frequency was identified in 94% of acute AF bipoles, 57% in persistent AF, and 76% after AERP recovery. Average correlation coefficient was 0.82 among acute AF bipoles, 0.63 in persistent AF, and 0.73 after AERP recovery. Conclusion: Transition from acute to persistent AF is associated with loss of spatiotemporal organization. A single dominant frequency recruits the majority of the left atrium in acute AF. Persistent AF, however, is associated with structural remodeling and dominant frequency dispersion. Recovery of refractoriness only partially restores spatiotemporal organization, indicating a major role for structural remodeling in the maintenance of persistent AF. [source]


Characterization of Paroxysmal and Persistent Atrial Fibrillation in the Human Left Atrium During Initiation and Sustained Episodes

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 6 2002
GJIN NDREPEPA M.D.
Characterization of AF in the LA.Introduction: Atrial fibrillation (AF) in the left atrium (LA) is poorly defined in terms of regional differences in the degree of organization, characteristics of paroxysmal and persistent variants, and electrophysiologic events that develop at the onset of episodes. Methods and Results: The study population consisted of 21 patients (15 men and 6 women; mean age 58 ▒ 9.4 years) with paroxysmal (10 patients) or persistent (11 patients) AF. Mapping of the LA during sustained episodes and the onset of AF was performed with a 64-electrode basket catheter. At the onset of AF, repetitive beats starting with atrial premature complexes and ending with generation of the earliest fibrillatory activity were defined as intermediary rhythm. Patients with paroxysmal AF had longer AF cycle lengths and more pronounced regional differences than patients with persistent AF. In total, AF cycle lengths in the LA in patients with persistent AF were 20% shorter than in patients with paroxysmal AF. Initiation of AF was preceded by an intermediary rhythm of 5.5 ▒ 2.5 cycles (6.3 ▒ 2.7 cycles in paroxysmal AF vs 4.2 ▒ 1.0 cycles in persistent AF; P = 0.026). At the onset of AF, the earliest generators of fibrillatory activity were located more frequently in the posterior wall of the LA. Conclusion: AF in the LA displays substantial regional differences in terms of AF cycle lengths and degree of organization. Patients with persistent AF have shorter cycle lengths and a higher degree of disorganized activity than patients with paroxysmal AF. Intermediary rhythms play an important role in initiation of AF via activation of generator regions in the LA. [source]


Sinoatrial Remodeling Caused by Persistent Atrial Fibrillation: What is the Relationship Between Postcardioversion Sinus Node Dysfunction and Increased Atrial Vulnerability?

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 7 2001
ARIF ELVAN M.D.
[source]


Significant Left Atrial Appendage Activation Delay Complicating Aggressive Septal Ablation during Catheter Ablation of Persistent Atrial Fibrillation

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 6 2010
CHEN-XI JIANG M.D.
Background:,This study aims to describe significant left atrial appendage activation following ablation of persistent atrial fibrillation, and explore its relationship with aggressive septal ablation. Methods and Results:,Significant left atrial appendage activation delay was found in 23 out of 201 patients undergoing persistent atrial fibrillation ablation. Of them, 14 were found in their index procedures, of whom septal line ablation was performed in nine (odds ratio 15.2, 95% confidence interval 4.6,50.8, P < 0.001). Another nine were found during their redo procedures (including two with biatrial activation dissociation), all of whom received extensive left septal complex fractionated electrograms ablation in their prior procedures (P = 0.002). Electrocardiograph showed split P wave with the latter component merged into the QRS wave. Activation mapping demonstrated the earliest breakthrough of the left atrium changed to coronary sinus in 18 (85.7%) patients. After 1 month, the mitral A wave velocity was 18.2 ▒ 17.0 cm/s, and decreased significantly as compared with preablation (20.2 ▒ 19.1 vs 58.2 ▒ 17.9 cm/s, P = 0.037) in patients undergoing redo procedures. Fourteen (60.9%) remained arrhythmia-free during follow-up for 10.6 ▒ 6.2 months. Conclusion:,Septal line ablation and extensive septal complex fractionated electrograms ablation are correlated with significant left atrial activation delay or even biatrial activation dissociation, and should be performed with prudent consideration. (PACE 2010; 33:652,660) [source]


Reversal of Atrial Remodeling after Cardioversion of Persistent Atrial Fibrillation Measured with Magnetocardiography

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 2 2009
MIKA LEHTO M.D.
Background: Atrial fibrillation (AF) causes electrical, functional, and structural changes in the atria. We examined electrophysiologic remodeling caused by AF and its reversal noninvasively by applying a new atrial signal analysis based on magnetocardiography (MCG). Methods: In 26 patients with persistent AF, MCG, signal-averaged electrocardiography (SAECG), and echocardiography were performed immediately after electrical cardioversion (CV), and repeated after 1 month in 15 patients who remained in sinus rhythm (SR). Twenty-four matched subjects without history of AF served as controls. P-wave duration (Pd) and dispersion (standard deviation of Pd values in individual channels) and root mean square amplitudes of the P wave over the last 40 ms portions (RMS40) were determined. Results: In MCG Pd was longer (122.8 ▒ 18.2 ms vs 101.5 ▒ 14.6 ms, P < 0.01) and RMS40 was higher (60.4 ▒ 28.2 vs 46.9 ▒ 19.1 fT) in AF patients immediately after CV as compared to the controls. In SAECG Pd dispersion was increased in AF patients. Mitral A-wave velocity and left atrial (LA) contraction were decreased and LA diameter was increased (all P < 0.01). After 1 month, Pd in MCG still remained longer and LA diameter greater (both P < 0.05), while RMS40 in MCG, Pd dispersion in SAECG, mitral A-wave velocity, and LA contraction were recovered. Conclusions: Magnetocardiographically detected atrial electrophysiologic alterations in persistent AF diminish rapidly although incompletely during maintained SR after CV. This might be related to the known early high and late lower, but still existent tendency to AF relapses. [source]


Electrophysiological Differences of the Spontaneous Onset of Paroxysmal and Persistent Atrial Fibrillation

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 3 2007
STEFAN WEBER M.D.
Background: Information about the spatiotemporal organization of atrial activity at the onset of atrial fibrillation (AF) is still limited. Methods: AF mapping was performed in 30 patients with AF (mean age 53 ▒ 9 years, 26 males) by deploying a noncontact mapping balloon in the left atrium (LA). Twenty-four patients had paroxysmal AF and six patients had persistent AF. Three types of AF episodes were analyzed: nonsustained AF (lasting , 30 seconds), sustained AF (lasting > 30 seconds, with spontaneous conversion or requiring internal cardioversion and subsequent stable sinus rhythm), and persistent AF episodes (stable sinus rhythm lasting , 1 minute after cardioversion). Results: A total of 101 spontaneous AF onset episodes were analyzed. Analysis of AF onset showed that there was a progressive shortening of the initial cycle lengths from nonsustained episodes to sustained episodes and to persistent AF episodes. There was an earlier and more rapid reduction in the cycle lengths from persistent episodes to sustained episodes and to nonsustained episodes of AF (P < 0.05 for persistent vs sustained and for sustained vs nonsustained episodes). The development of multiwavelet activity and disorganization of conduction occurred earlier in persistent and sustained episodes than in nonsustained AF episodes. LA size was greater in patients with persistent AF episodes compared with patients with sustained or nonsustained AF episodes. Conclusions: Electrophysiological events that develop at the onset of AF seem to be different in different types of AF. A more rapid degeneration into the fibrillatory activity was observed in persistent and sustained AF than in nonsustained AF episodes. [source]


Discordant Regulation of CRP and NT-proBNP Plasma Levels After Electrical Cardioversion of Persistent Atrial Fibrillation

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 6 2006
AXEL BUOB
Background: B-type natriuretic peptide (BNP) and C-reactive protein (CRP) have been suggested to be prognostically relevant markers in patients with cardiovascular disease. Additionally, BNP and CRP plasma levels seem to be independently elevated in patients with atrial fibrillation (AF). However, there are only sparse data about the significance and temporal course of these plasma markers after restoration of sinus rhythm (SR). Methods: We performed a prospective study in consecutive patients with symptomatic atrial fibrillation. NT-proBNP and CRP plasma levels were measured before and one month after electrical cardioversion (CV). Patients with infections, an acute coronary syndrome, or surgery 4 weeks prior to CV, were excluded. Result: Twenty-five patients (men 84%, age 66 ▒ 8 years, duration of AF 90 ▒ 75 days, left ventricular ejection fraction 0.57 ▒ 0.11) were analyzed. At follow-up (33 ▒ 6 days after CV) 14 patients (56%) were in SR and 11 patients (44%) in AF. In patients with SR there was a significant reduction of NT-proBNP levels (baseline 1647 ▒ 1272 pg/mL, follow-up 772 ▒ 866 pg/mL, P < 0.05), even in a subgroup of patients (n = 10) with normal left ventricular ejection fraction (1262 ▒ 538 vs 413 ▒ 344 pg/mL, P < 0.001). CRP levels in patients with SR were similar at baseline and at follow-up (3.5 ▒ 3.6 vs 3.2 ▒ 2.5 mg/L, P = 0.8). Conclusion: We conclude that even in patients with normal left ventricular ejection fraction restoration of sinus rhythm leads to a significant reduction of NT-proBNP plasma levels. In contrast, CRP plasma levels seem not to be influenced during the first 4 weeks after electrical cardioversion. [source]


Determinants of Persistent Atrial Fibrillation in Patients with DDD Pacemaker Implantation

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 3 2003
AHMET DURAN DEMIR
DEMIR, A.D., et al.: Determinants of Persistent Atrial Fibrillation in Patients with DDD Pacemaker Implantation.Occurrence of AF in a pacemaker implanted patient is a significant cause of morbidity and mortality. The aim of this study was to prospectively investigate the clinical, echocardiographic, and electrocardiographic determinants of persistent AF in patients with DDD pacemakers. A 101 consecutive patients were followed for an average of19.8 ▒ 11.8months. Persistent AF was documented in 21 (20.8%) patients and 80 (79.2%) patients were in sinus or physiologically paced rhythm. In patients with persistent AF, previous AF attacks were observed more frequently(P < 0.03)and left atrial dimension was higher(3.5 ▒ 0.6vs3.0 ▒ 0.5 cm, P < 0.001). Average P maximum and P wave dispersion (PWD) values calculated in a 12-lead surface electrocardiogram were also found to be significantly higher in patients with persistent AF(P < 0.001). Cox regression analysis demonstrated that the presence of previous AF attacks(RR 8.95, P < 0.001), increased left atrial dimension(RR 2.1, P < 0.02), P maximum duration120 ms (RR 6.1, P < 0.001), and PWD 40 ms(RR 12.2, P < 0.001)were associated with an increased risk of persistent AF. Cut-off points were 120 ms for P maximum and 40 ms for PWD. Sensitivity, specificity, and positive and negative predictive values were calculated as 76.2, 82.5, 53.3, and 92.9 for P maximum and as 85.7, 87.5, 64.3, and 95.9 for PWD, respectively. In patients with DDD pacemakers, previous AF attacks, increased left atrial dimension, P maximum value of 120 ms, and a PWD value of 40 ms were associated with a significantly increased risk of persistent AF. These patients must further be managed with other treatment modalities to prevent the development of persistent AF. (PACE 2003; 26:719,724) [source]


First time and repeat cardioversion of atrial tachyarrhythmias , a comparison of outcomes

INTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 8 2010
A. Arya
Summary Introduction:, Repeat cardioversion may be necessary in over 50% of patients with persistent atrial fibrillation (AF), but identifying responders remains challenging. This study evaluates the long-term success of direct current cardioversion (DCCV) and the clinical and echocardiographical parameters that influence them, in over 1000 sedation-cardioversion procedures undertaken at Eastbourne General Hospital between 1996 and 2006. Methods:, A total of 770 patients of mean age (SD) 70.1(10.1) underwent 1013 DCCVs (first n = 665, repeat n = 348) for atrial tachyarrhythmias from 1996 to 2006. Time to persistent arrhythmia recurrence was compared between first and multiple DCCV, and the effect of age, gender, presence of heart disease, left atrial size, fractional shortening, arrhythmia duration, anti-arrhythmic drug therapy (AAD) and other concomitant cardiac medication was evaluated using the Kaplan,Meier method and Cox's Proportional-hazards model. Results:, In all, 33% of first and 29% of repeat DCCVs were in sinus rhythm (SR) at 12 months (m). There was no difference in median time to arrhythmia recurrence (SE) between first and multiple procedures: 1.5 ▒ 0.1 m (1.3,1.7) and 1.5 ▒ 0.0 m (1.4,1.6) respectively, p = 0.45. AAD use was significantly higher, arrhythmia duration shorter and more diabetic patients underwent repeat procedures. Amiodarone, OR 0.56, p = 0.04, sotalol, OR 0.61, p = 0.02 and arrhythmia duration, < 6 m, OR 0.72, p = 0.03 were independent predictors of improved outcome in first procedures only. In patients undergoing first procedures on amiodarone or sotalol, median time to arrhythmia recurrence was longer and 12 m SR rates higher, 6.0 ▒ 2.4 m (42%) than those who had a repeat procedure on the same medication, 1.5 ▒ 0.1 m (33%), p = 0.06. Conclusions:, The efficacy of first and subsequent DCCV procedures is similar, achieving a similar proportion of SR maintenance at 1 year. However, the benefits of AAD therapy are the greatest following first time procedures. Concomitant AAD therapy should be considered for all first time procedures for persistent AF. [source]


A Short-Term, Randomized, Double-Blind, Parallel-Group Study to Evaluate the Efficacy and Safety of Dronedarone versus Amiodarone in Patients with Persistent Atrial Fibrillation: The DIONYSOS Study

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 6 2010
JEAN-YVES LE HEUZEY M.D.
Dronedarone versus Amiodarone in Patients with AF.,,Introduction: We compared the efficacy and safety of amiodarone and dronedarone in patients with persistent atrial fibrillation (AF). Methods: Five hundred and four amiodarone-na´ve patients were randomized to receive dronedarone 400 mg bid (n = 249) or amiodarone 600 mg qd for 28 days then 200 mg qd (n = 255) for at least 6 months. Primary composite endpoint was recurrence of AF (including unsuccessful electrical cardioversion, no spontaneous conversion and no electrical cardioversion) or premature study discontinuation. Main safety endpoint (MSE) was occurrence of thyroid-, hepatic-, pulmonary-, neurologic-, skin-, eye-, or gastrointestinal-specific events, or premature study drug discontinuation following an adverse event. Results: Median treatment duration was 7 months. The primary composite endpoint was 75.1 and 58.8% with dronedarone and amiodarone, respectively, at 12 months (hazard ratio [HR] 1.59; 95% confidence interval [CI] 1.28,1.98; P < 0.0001), mainly driven by AF recurrence with dronedarone compared with amiodarone (63.5 vs 42.0%). AF recurrence after successful cardioversion was 36.5 and 24.3% with dronedarone and amiodarone, respectively. Premature drug discontinuation tended to be less frequent with dronedarone (10.4 vs 13.3%). MSE was 39.3 and 44.5% with dronedarone and amiodarone, respectively, at 12 months (HR = 0.80; 95% CI 0.60,1.07; P = 0.129), and mainly driven by fewer thyroid, neurologic, skin, and ocular events in the dronedarone group. Conclusion: In this short-term study, dronedarone was less effective than amiodarone in decreasing AF recurrence, but had a better safety profile, specifically with regard to thyroid and neurologic events and a lack of interaction with oral anticoagulants. (J Cardiovasc Electrophysiol, Vol. 21, pp. 597-605, June 2010) [source]


Sotalol and a Broken Heart

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 2 2010
F.H.R.S., PETER L. FRIEDMAN M.D., Ph.D.
Sotalol and a Broken Heart., An 82-year-old woman with persistent atrial fibrillation underwent successful electrical cardioversion and was begun on sotalol. After 3 days of in-hospital observation she had only mild lengthening of the QT interval. Two weeks later in clinic, the day after her husband's unexpected death, she was noted to have profound QT interval prolongation. Although she was asymptomatic and echocardiography did not disclose regional wall motion abnormalities consistent with takotsubo cardiomyopathy, she probably had a forme fruste of stress cardiomyopathy. Following emotional trauma, a period of heightened vigilance for ventricular proarrhythmia is probably warranted in women treated with antiarrhythmic drugs that lengthen repolarization. (J Cardiovasc Electrophysiol, Vol. 21, pp. 207-210, February 2010) [source]


Clinical Experience with a Single Catheter for Mapping and Ablation of Pulmonary Vein Ostium

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 4 2009
PAOLO DE FILIPPO M.D.
Introduction: The aim of this single center study is to evaluate the safety and the efficacy of performing pulmonary vein isolation (PVI) using a single high-density mesh ablator (HDMA) catheter. Methods: A total of 17 consecutive patients with paroxysmal (10 patients) or persistent atrial fibrillation (7 patients) and no heart disease were enrolled. A single transseptal puncture was performed and the HDMA was placed at each PV ostium identified with anatomic and electrophysiological mapping. Pulsed radiofrequency (RF) energy was delivered at the targeted temperature of 58░C with maximum power of 80 watts. No other ablation system was utilized. The primary objective of the study was acute isolation of the targeted PV, and the secondary objective was clinical efficacy and safety of PVI with HDMA for atrial fibrillation (AF) prevention. Patients were followed at intervals of 1, 3, 6, and 12 months. Results: PVI was attempted with HDMA in 67/67 PVs. [Correction made after online publication October 27, 2008: PVs changed from 6/67 to 67/67] Acute success rate were: 100% (16/16) for left superior PV, 100% (16/16) for left inferior PV, 100% (17/17) for right superior PV, 100% (1/1) for left common trunk and 47% (8/17) for right inferior PV. Total procedure time was 200 ▒ 36 minutes (range 130,240 minutes) and total fluoroscopy time was 42 ▒ 18 minutes (range 23,75 minutes). During a mean follow-up of 11 ▒ 4 months, 64% of patients remained in sinus rhythm (8/10 paroxysmal AF and 3/7 for persistent AF). No complications occurred either acutely or at follow-up. Conclusions: PV isolation with HDMA is feasible and safe. The midterm efficacy in maintaining sinus rhythm is higher in paroxysmal than in persistent patients. [source]


State of the Art: Catheter Ablation of Atrial Fibrillation

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 6 2008
MATTHEW WRIGHT M.B.B.S., Ph.D.
Curative treatment of atrial fibrillation with catheter ablation is now a legitimate option for a large number of patients. In the last decade a tremendous amount has been discovered about this fascinating arrhythmia, yet there is still much that is understood. A number of different ablation strategies have been used including pulmonary vein isolation, targeting of fractionated electrograms, compartmentalising the atria with linear lesions and various combinations and modifications of these lesion sets. The optimal ablation strategy for both paroxysmal and long-lasting persistent atrial fibrillation is unknown. In this review the possible mechanisms underlying atrial fibrillation are examined along with the current catheter ablation techniques used in the treatment atrial fibrillation. [source]


Catheter Ablation of Long-Lasting Persistent Atrial Fibrillation: Critical Structures for Termination

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 11 2005
MICHEL HA¤SSAGUERRE M.D.
Background: The relative contributions of different atrial regions to the maintenance of persistent atrial fibrillation (AF) are not known. Methods: Sixty patients (53 ▒ 9 years) undergoing catheter ablation of persistent AF (17 ▒ 27 months) were studied. Ablation was performed in a randomized sequence at different left atrial (LA) regions and comprised isolation of the pulmonary veins (PV), isolation of other thoracic veins, and atrial tissue ablation targeting all regions with rapid or heterogeneous activation or guided by activation mapping. Finally, linear ablation at the roof and mitral isthmus was performed if sinus rhythm was not restored after addressing the above-mentioned areas. The impact of ablation was evaluated by the effect on the fibrillatory cycle length in the coronary sinus and appendages at each step. Activation mapping and entrainment maneuvers were used to define the mechanisms and locations of intermediate focal or macroreentrant atrial tachycardias. Results: AF terminated in 52 patients (87%), directly to sinus rhythm in 7 or via the ablation of 1,6 intermediate atrial tachycardias (total 87) in 45 patients. This conversion was preceded by prolongation of fibrillatory cycle length by 39 ▒ 9 msec, with the greatest magnitude occurring during ablation at the anterior LA, coronary sinus and PV-LA junction. Thirty-eight atrial tachycardias were focal (originating dominantly from these same sites), while 49 were macroreentrant (involving the mitral or cavotricuspid isthmus or LA roof). Patients without AF termination displayed shorter fibrillatory cycles at baseline: 130 ▒ 14 vs 156 ▒ 23 msec; P = 0.002. Conclusion: Termination of persistent AF can be achieved in 87% of patients by catheter ablation. Ablation of the structures annexed to the left atrium,the left atrial appendage, coronary sinus, and PVs,have the greatest impact on the prolongation of AF cycle length, the conversion of AF to atrial tachycardia, and the termination of focal atrial tachycardias. [source]


Reversal of Electrical Remodeling After Cardioversion of Persistent Atrial Fibrillation

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 5 2004
MERRITT H. RAITT M.D.
Introduction: In animals, atrial fibrillation results in reversible atrial electrical remodeling manifested as shortening of the atrial effective refractory period, slowing of intra-atrial conduction, and prolongation of sinus node recovery time. There is limited information on changes in these parameters after cardioversion in patients with persistent atrial fibrillation. Methods and Results: Thirty-eight patients who had been in atrial fibrillation for 1 to 12 months underwent electrophysiologic testing 10 minutes and 1 hour after cardioversion. At 1 week, 19 patients still in sinus rhythm returned for repeat testing. Reverse remodeling of the effective refractory period was not uniform across the three atrial sites tested. At the lateral right atrium, there was a highly significant increase in the effective refractory period between 10 minutes and 1 hour after cardioversion (drive cycle length 400 ms: 204 ▒ 17 ms vs 211 ▒ 20 ms, drive cycle length 550 ms: 213 ▒ 18 ms vs 219 ▒ 23 ms, P < 0.001). The effective refractory period at the coronary sinus and distal coronary sinus did not change in the first hour but had increased by 1 week. The corrected sinus node recovery time did not change in the first hour but was shorter at 1 week (606 ▒ 311 ms vs 408 ▒ 160 ms, P = 0.009). P wave duration also was shorter at 1 week (135 ▒ 18 ms vs 129 ▒ 13 ms, P = 0.04) consistent with increasing atrial conduction velocity. Conclusion: The atrial effective refractory period increases, sinus node function improves, and atrial conduction velocity goes up in the first week after cardioversion of long-standing atrial fibrillation in humans. Reverse electrical remodeling of the effective refractory period occurs at different rates in different regions of the atrium. (J Cardiovasc Electrophysiol, Vol. 15, pp. 507-512, May 2004) [source]


Significant Left Atrial Appendage Activation Delay Complicating Aggressive Septal Ablation during Catheter Ablation of Persistent Atrial Fibrillation

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 6 2010
CHEN-XI JIANG M.D.
Background:,This study aims to describe significant left atrial appendage activation following ablation of persistent atrial fibrillation, and explore its relationship with aggressive septal ablation. Methods and Results:,Significant left atrial appendage activation delay was found in 23 out of 201 patients undergoing persistent atrial fibrillation ablation. Of them, 14 were found in their index procedures, of whom septal line ablation was performed in nine (odds ratio 15.2, 95% confidence interval 4.6,50.8, P < 0.001). Another nine were found during their redo procedures (including two with biatrial activation dissociation), all of whom received extensive left septal complex fractionated electrograms ablation in their prior procedures (P = 0.002). Electrocardiograph showed split P wave with the latter component merged into the QRS wave. Activation mapping demonstrated the earliest breakthrough of the left atrium changed to coronary sinus in 18 (85.7%) patients. After 1 month, the mitral A wave velocity was 18.2 ▒ 17.0 cm/s, and decreased significantly as compared with preablation (20.2 ▒ 19.1 vs 58.2 ▒ 17.9 cm/s, P = 0.037) in patients undergoing redo procedures. Fourteen (60.9%) remained arrhythmia-free during follow-up for 10.6 ▒ 6.2 months. Conclusion:,Septal line ablation and extensive septal complex fractionated electrograms ablation are correlated with significant left atrial activation delay or even biatrial activation dissociation, and should be performed with prudent consideration. (PACE 2010; 33:652,660) [source]


Evaluating Patients with Acute Ischemic Stroke with Special Reference to Newly Developed Atrial Fibrillation in Cerebral Embolism

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 9 2007
MINORU TAGAWA M.D.
Background:Cardioembolic strokes are extensive and have a poor prognosis. To identify the cardiovascular risk factors of cardioembolic stroke, we evaluated the cardiovascular status with special reference to persistent atrial fibrillation (AF) and paroxysmal atrial fibrillation (PAF) combined with the type of acute ischemic stroke. Methods:We divided 315 consecutive patients admitted to our Department of Neurosurgery with an acute ischemic stroke into four types of brain infarction using clinical history, onset pattern of stroke, and brain imaging: cardioembolic (group E, n = 105), lacunar (group L, n = 92), atherothrombotic (group T, n = 111), and unclassified (n = 7). All patients underwent standard electrocardiography (ECG), a 24-hour ECG recording (Holter ECG) and transthoracic echocardiography (UCG). Results:Persistent AF or PAF was detected in 97 patients (31.5%) using Holter ECG: more frequently in group E (67.6%) than in groups L (15.2%) or T (9.2%). Persistent AF or PAF was first diagnosed on admission using a standard ECG in 16 patients (5.2%) with no previous history and 14 of these patients belonged to group E (13.3%). PAF was newly detected on Holter ECG in another 26 patients (8.4%) and 13 of these patients (12.4%) belonged to group E. Concerning UCG, left atrial enlargement and mitral regurgitation were more frequent in group E than in group L or T. Conclusion:Holter ECG in addition to ECG on admission is important for detecting persistent AF or PAF in patients with ischemic stroke, especially with cardioembolism as diagnosed by neuroimaging. [source]